Expression of Borderline Personality Disorder Symptoms across

233 Pages·2016·1.66 MB·English

University of Kentucky
UKnowledge
Theses and Dissertations--Psychology Psychology
2013
Expression of Borderline Personality Disorder Symptoms across
the Ovulatory Cycle: A Multilevel Investigation
Tory A. Eisenlohr-Moul
University of Kentucky,
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The document mentioned above has been reviewed and accepted by the student’s advisor, on
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Tory A. Eisenlohr-Moul, Student
Dr. C. Nathan DeWall, Major Professor
Dr. David T. Berry, Director of Graduate Studies
EXPRESSION OF BORDERLINE PERSONALITY DISORDER SYMPTOMS
ACROSS THE OVULATORY CYCLE: A MULTILEVEL INVESTIGATION

__________________________

DISSERTATION
___________________________

A dissertation submitted in partial fulfillment of the
requirements for the degree of Doctor of Philosophy
in the College of Agriculture at the University of Kentucky

By
Tory Anne Eisenlohr-Moul

Lexington, Kentucky

Co-Directors: C. Nathan DeWall, Ph.D., Professor of Psychology
and Suzanne C. Segerstrom, Ph.D., Professor of Psychology

Lexington, Kentucky

2013

Copyright © Tory Anne Eisenlohr-Moul 2013
ABSTRACT OF DISSERTATION

EXPRESSION OF BORDERLINE PERSONALITY DISORDER SYMPTOMS
ACROSS THE OVULATORY CYCLE: A MULTILEVEL INVESTIGATION

Borderline Personality Disorder (BPD) is a disabling condition characterized by chronic
emotion dysregulation and behavioral impulsivity. Prospective studies that test proposed
mechanisms of within-person change in BPD hold the key to improving symptom
predictability and control in this disorder. A small body of evidence suggests that
fluctuations in estradiol such as those occurring naturally at ovulation during the monthly
female reproductive cycle may increase symptoms in women with BPD (DeSoto et al.,
2003). Furthermore, there is preliminary evidence that both self-esteem and feelings of
social rejection are highest at ovulation, when estradiol peaks (Durante and Hill, 2009;
Eisenlohr-Moul et al., under review). Such feelings have been reliably linked to increases
in BPD-related behavior in all individuals (e.g., Twenge et al., 2002). The purpose of this
dissertation was to test a cyclical vulnerability model for women with BPD in which
ovulatory estradiol shifts are associated with reductions in felt social acceptance, which
in turn are associated with increased BPD symptom expression. 40 women, sampled to
achieve a flat distribution of BPD symptoms, completed 28 daily diaries online, as well
as four 1-hour weekly visits to the laboratory to complete longer assessments and provide
saliva samples, which were assayed for estradiol. In addition, participants underwent the
Structured Clinical Interview for the Diagnosis of BPD at the end of the study.
Results of multilevel models revealed the opposite of the predicted effects of within-
person changes in estradiol and their interaction with trait BPD. The data suggest a
pattern in which women high in trait BPD show increases in felt acceptance and
reductions in BPD symptom expression at higher levels of conception probability and
higher-than-usual levels of estradiol. Women low in trait BPD show the opposite pattern
in some cases. Several alternative moderators were tested, and results suggest that some
risk factors for BPD (e.g., Neuroticism, Sexual Abuse) interact with high trait levels of
estradiol to predict greater symptoms. Both average levels of estradiol and monthly
fluctuations in estradiol may have relevance for women with BPD. It is recommended
that future studies utilize clinical samples and additional physiological measures to
further elucidate the mechanisms through which estradiol exerts clinically-relevant
change.

KEY WORDS: Borderline Personality Disorder, 17-Beta Estradiol, Menstrual Cycle,
Ovulation
Tory Anne Eisenlohr-Moul

April 24, 2013
EXPRESSION OF BORDERLINE PERSONALITY DISORDER SYMPTOMS
ACROSS THE OVULATORY CYCLE: A MULTILEVEL INVESTIGATION

By
Tory Anne Eisenlohr-Moul

C. Nathan DeWall, Ph.D.
Co-Director of Dissertation

Suzanne C. Segerstrom, Ph.D.
Co-Director of Dissertation

David T. Berry, Ph.D.
Director of Graduate Studies

April 24, 2013
Date
ACKNOWLEDGMENTS

I’d like to thank a few people by name for their roles in my completion of this
dissertation. Mother and Father: You instilled in me an appreciation for education at a
very early age, and a great deal of my success can be traced back to your love and
encouragement. Dr. Erin Walsh: The tenderness you feel toward strangers continues to
inspire me, but thanks for loving me best. Jessica Peters: It’s been so important for me to
have a friend like you who really understands me. Thanks for every little thing you’ve
done for me—but especially for your assistance on this project. Kaitlyn Chamberlain:
Thank you for your dedication and hard work in helping me to run participants through
this protocol. I’d also like to acknowledge funding received through a petit grant from
the Center for Drug and Alcohol Research, without which this work would not have been
possible, and resources from the Center for Drug Abuse Research Translation. Thank you
to my patients with Borderline Personality Disorder, whose passion and intensity delights
me. Last but not least, I’d like to thank the three people who have had the strongest
influence on my development as a clinical scientist. Dr. Ruth Baer: Thank you for
modeling equanimity, demonstrating kindness, and teaching me how to be effective in
helping those who suffer. Dr. Nathan DeWall: You have been so supportive of me. Thank
you for your kindness and for mentoring me in efficiency and self-assuredness. You
helped me to become a much more productive scientist. Dr. Suzanne Segerstrom: Thank
you for modeling genuine curiosity, methodological rigor, and passion for the field. You
never settled for anything less than my best, and I’m deeply grateful to you for that.

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TABLE OF CONTENTS
ACKNOWLEDGMENTS ................................................................................................. iii
LIST OF TABLES ............................................................................................................. vi
LIST OF FIGURES ........................................................................................................... ix
Chapter One: Introduction .................................................................................................. 1
Borderline Personality Disorder ..................................................................................... 1
The Reproductive Cycle and BPD Symptoms: Could Hormones Play a Role? ............. 2
A New Cyclical Vulnerability Theory of BPD in Women ............................................. 5
FFM Personality Abnormalities: Alternative Moderators of Cyclical Vulnerability ..... 6
A Special Case of Linehan’s Biosocial Model of BPD: Aspects of Childhood ............. 7
Maltreatment as Alternative Moderators of Cyclical Vulnerability ............................... 7
Alternative Mechanisms of Cycle-Related Change in BPD Symptoms ......................... 8
Global Self-Control as an Alternative Mediator ......................................................... 9
Aspects of Impulsivity as Alternative Mediators ........................................................ 9
The Present Study: Aims and Hypotheses .................................................................... 10
Chapter Two: Method ....................................................................................................... 12
Overview and Study Design ......................................................................................... 12
Participants .................................................................................................................... 12
Procedure ...................................................................................................................... 13
Screening and Recruitment ....................................................................................... 13
Weekly Laboratory Protocol ..................................................................................... 13
Follow-Up Risk Assessment Protocol ...................................................................... 16
Daily Diary Protocol ................................................................................................. 16
Weekly Measures .......................................................................................................... 17
17β-Estradiol ............................................................................................................. 17
Weekly BPD Symptoms ........................................................................................... 18
Weekly Feelings of Social Acceptance ..................................................................... 20
Weekly Self-Control ................................................................................................. 20
Weekly Impulsivity ................................................................................................... 21
Daily Measures ............................................................................................................. 22
Conception Probability ............................................................................................. 22
Daily BPD Symptoms ............................................................................................... 22
Daily Felt Acceptance ............................................................................................... 23
Between-Person Measures ............................................................................................ 23
Five Factor Model (FFM) Personality ...................................................................... 23
Childhood Maltreatment ........................................................................................... 24
DSM-IV Diagnosis of BPD ...................................................................................... 24
Data Analytic Plan ........................................................................................................ 25
Power Analysis ......................................................................................................... 25
Multilevel Models ..................................................................................................... 25
Model Fitting and Random Effects ........................................................................... 26
Specific Hypothesis Tests ......................................................................................... 27
Observations at the Daily and Weekly Level ............................................................... 30
Descriptive and Correlational Analyses ........................................................................ 30
iv
Testing Hypothesis 1: Ovulation, Estradiol, and BPD Symptom Expression .............. 33
Testing Hypothesis 2: Moderation of Cycle Effects by Trait BPD .............................. 39
Testing Hypothesis 3a: Mediation by Felt Social Acceptance ..................................... 56
Testing Hypothesis 3b and 3c: Mediation by Impulsivity and Self-Control ................ 74
Testing Alternative Moderators: Dismantling Trait BPD Moderation Effects Using
FFM Personality and Childhood Maltreatment .......................................................... 125
Chapter Four: Discussion ................................................................................................ 180
Do Ovulation or Increases in Estradiol Predict Greater BPD Symptoms? ................. 181
Do Ovulation or Increases in Estradiol Predict Lower Felt Acceptance? .................. 184
Alternative, Proximal Mediators: Are Changes in Self-Control or Impulsivity
Responsible for Cycle Effects? ................................................................................... 185
Investigating Alternative Moderators of Cyclical and Hormonal Effects: Roles of FFM
Personality and Childhood Maltreatment ................................................................... 187
Contextualizing the Present Findings in the Extant Literature on the Cycle and BPD
..................................................................................................................................... 191
Using Biosocial and Evolutionary Theories to Understand the Effects of the Cycle on
BPD Symptoms ........................................................................................................... 193
Using FFM and Biosocial Theories of BPD to Understand the Effects of Average
Levels of Estradiol on BPD Symptoms ...................................................................... 195
Limitations and General Recommendations for Future Work in this Area ................ 201
Clinical Implications and Directions for Future Clinical Research ............................ 203
Conclusions ................................................................................................................. 205
References ....................................................................................................................... 206
CURRICULUM VITAE ................................................................................................. 217

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LIST OF TABLES

Table 1. Demographic Sample Characteristics………………………………………..…14
Table 2. Zero-order correlations among between-person measures, average estradiol, and
average daily and weekly measures of BPD……………………………………………..31
Table 3. Multilevel Poisson Regression Models Predicting Daily PAI-BOR Scores from
Daily Conception Probability Values……………………………………………………34
Table 4. Multilevel Poisson Regression Models Predicting Weekly BPD Symptoms from
Average Levels of Estradiol and Weekly Deviations in Estradiol……………………....36
Table 5. Multilevel Poisson Regression Models Predicting Daily PAI-BOR Scores from
the Interaction of Daily Conception Probability Values and Average of Weekly PAI-BOR
Assessments (Trait BPD) ……………………………………………………………….40
Table 6. Multilevel Poisson Regression Models Predicting Daily PAI-BOR Scores from
the Interaction of Daily Conception Probability Values and Number of SCID-II BPD
Criteria Met (Trait BPD) ………………………………………………………………..44
Table 7. Multilevel Poisson Regression Models Predicting Weekly BPD Symptoms from
the Interaction of Average of Weekly PAI-BOR Assessments (Trait BPD) with Average
Estradiol and Weekly Deviations in Estradiol…………………………………………..47
Table 8. Multilevel Poisson Regression Models Predicting Weekly BPD Symptoms from
the Interaction of Number of SCID-II Criteria Met (Trait BPD) with Average Estradiol
and Weekly Deviations in Estradiol……………………………………………………..57
Table 9. Multilevel Poisson Regression Models Predicting Daily Felt Acceptance from
Daily Conception Probability Values……………………………………………………60
Table 10. Multilevel Poisson Regression Models Predicting Daily Felt Acceptance from
the Interaction of Daily Conception Probability Values and Average of Weekly PAI-BOR
Assessments (Trait BPD) ………………………………………………………………..62
Table 11. Multilevel Poisson Regression Models Predicting Daily Felt Acceptance from
the Interaction of Daily Conception Probability Values and Number of SCID-II BPD
Criteria Met (Trait BPD) ………………………………………………………………...63
Table 12. Multilevel Regression Models Predicting Weekly Felt Acceptance from
Average Estradiol and Weekly Deviations in Estradiol…………………………………66
Table 13. Multilevel Regression Models Predicting Weekly Felt Acceptance from the
Interaction of Average Weekly PAI-BOR Total Score with Average Estradiol and
Weekly Deviations in Estradiol………………………………………………………….67
Table 14. Multilevel Poisson Regression Models Predicting Daily PAI-BOR Scores from
Average Levels of Daily Felt Acceptance and Daily Deviations in Felt Acceptance…...68
Table 15. Multilevel Poisson Regression Models Predicting Weekly BPD Symptoms
from Average Levels of Weekly Felt Acceptance and Weekly Deviations in Felt
Acceptance……………………………………………………………………………….72
Table 16. Multilevel Regression Models Predicting Weekly Self-Control and Impulsivity
from Average Estradiol and Weekly Deviations in Estradiol……………………………80
Table 17. Multilevel Regression Models Predicting Weekly Self-Control and Impulsivity
from the Interaction of Average Weekly PAI-BOR Total Score with Average Estradiol
and Weekly Deviations in Estradiol……………………………………………………..82
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